What’s going on with A&E waiting times?

Waiting times in accident and emergency (A&E) departments are a key measure of how the NHS is performing. Here, we look at who is using A&E services, why people have been waiting longer in A&E in recent years, and what is being done nationally to address long waiting times.

The different types of A&E departments

There are three main types of A&E department in England.

Type 1 departments are what most people might traditionally think of as an A&E service. They are major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients – for example, patients in cardiac arrest. Type 1 departments, which are operated by 122 NHS trusts, account for the majority of attendances.

Type 2 departments are consultant-led facilities but for specific conditions – for example, eye conditions or dental problems.

Type 3 departments treat minor injuries and illnesses, such as stomach aches, cuts and bruises, some fractures and lacerations, and infections or rashes.

A&E department waiting times

Being treated quickly in A&E is important both for clinical outcomes and for patient experience, as delays in care for people arriving in A&E have been associated with increased mortality and illness.

The most high-profile measure of A&E performance in England is the four-hour standard. This refers to the pledge in the NHS Constitution that at least 95% of patients attending A&E should be admitted to hospital, transferred to another provider, or discharged within four hours.

A&E waiting times are often used as a barometer for overall performance of the NHS and social care system. This is because A&E waiting times are affected by activity and pressures in other services, such as the ambulance service, primary care, community-based care and social care services. For example, patients cannot be admitted quickly from A&E to a hospital ward if hospitals are full due to delays in transferring patients to other NHS services or in arranging social care (for more details, see our nutshell on NHS waiting times: how are different service waiting times linked? ).

However, measuring the proportion of people seen within four hours does not provide a complete picture of how A&E departments are performing, and we should be cautious about placing too much emphasis on the four-hour standard or any single measure of A&E performance. The 2022 national survey of patients who have used urgent and emergency care services also shows that these services receive high satisfaction scores overall, although satisfaction has fallen in recent years and more could be done to improve communication with patients as they are discharged from A&E.

What has happened to A&E waiting times in recent years?

A&E waiting times have worsened substantially in recent years, after a decade of funding settlements that failed to keep up with demand for services and growing staff shortages. The NHS has not met the four-hour standard at national level in any year since 2013/14, and the standard has been missed at a national level every month since July 2015 (see Figure 1).

The four-hour standard is measured across all types of A&E department, but performance is poorest in type 1 (major) A&Es, where most breaches of the four-hour standard occur.

In 2023/24, waiting time performance in A&E departments was among the worst recorded in modern data collections. Only 72% of people were seen within four hours in A&E (compared to the national target of 95%) and far fewer NHS trusts reported achieving the national standard. A&E departments have recently started to record the number of people who wait more than 12 hours from arrival. In April 2024, 10% of people attending A&E waited more than 12 hours in total.

Why are patients waiting longer in A&E departments?

People are waiting longer in A&E departments due to a wide range of factors, including rising demand for services and reduced capacity to meet this demand.

Rising A&E attendances

High volumes of A&E attendances can lead to overcrowding, rising pressure on A&E services, and poorer experience for patients. During the Covid-19 pandemic, attendances were lower than usual due to a range of factors including changes to behaviour (eg fewer accidents due to sporting injuries) and changing public attitudes to using health care services; however, demand has since returned (see Figure 2). The overall trend shows that the number of people going to A&E has risen substantially over time. In 2023/24, there were 26.2 million attendances at A&E, compared with 21.6 million in 2011/12.

Rising emergency admissions to hospital

However, the increased pressure on A&E departments is more closely associated with rising numbers of emergency admissions to hospital rather than the increase in A&E attendances. In recent years, as demand for hospital inpatient care has increased, the capacity to meet this demand has come under increasing pressure due to an insufficient number of hospital beds and severe staff shortages (see our explainer on NHS hospital bed numbers for more information).

Fewer hospital beds

Although medical advances have reduced the average length of time people spend in hospital, enabling beds to be ‘turned around’ or made available again more quickly, rising emergency admissions are placing increasing pressure on available resources, including hospital beds.

These pressures are demonstrated by high levels of bed occupancy in NHS hospitals, which are closely associated with longer waiting times in A&E. Particularly in the winter months, hospitals are routinely operating with bed occupancy rates above 92% – the level at which the Department of Health and Social Care suggests that hospitals will struggle to deal with emergency admissions. that hospitals will struggle to deal with emergency admissions.

One of the clearest indications of the link between A&E waiting times and hospital bed occupancy is the number of patients who experience ‘trolley waits’1 in A&E departments – ie, a long wait between a decision being made in A&E to admit the patient and the patient actually being admitted to a hospital bed. These waits have substantially increased in recent years – from less than 150 in the first quarter of 2014 to nearly 150,000 in the first quarter of 2024 (see Figure 3).

Pressures on other services and changing clinical practice

Delays in discharging patients who are medically fit to leave hospital (known as ‘delayed transfers of care’ or ‘stranded patients’) are another factor driving up bed occupancy rates. This can mean both poorer experience for the patients waiting to be discharged and a lack of available beds for new patients requiring admission from A&E. These delays can arise due to a lack of available capacity in social care and NHS settings outside of hospital – including intermediate care or ‘step-down’ facilities that help care for patients after they leave hospital.

Waiting times in A&E may also be increasing due to advances in medical practice. For example, some patients who would previously have been admitted to hospital can now be fully treated in A&E with more investigations and treatments.

Staffing pressures

A&E departments face longstanding challenges in recruiting and retaining sufficient staff to cope with rising demand. The Royal College of Emergency Medicine notes that emergency medicine has a high attrition rate from doctors in training, high early retirement rates for experienced clinicians, and significant reliance on temporary locum clinical staff. In a recent survey by the General Medical Council, nearly three-quarters of emergency medicine trainees rated the intensity of their workload as heavy or very heavy – substantially more than any other specialty.

There has been steady growth in the emergency medicine workforce in recent years – for example, between 2014 and 2024 the number of emergency medicine consultants increased by 6% on average each year. Over this time, other professional roles, such as advanced clinical practitioners and physician associates, have also been developed to play a greater role in delivering A&E services to relieve pressures on departments. The NHS Long Term Workforce Plan sets out a plan to expand some of these roles to increase staffing numbers.

However, it remains difficult to recruit and retain sufficient staff in emergency care and other key hospital services to meet growing demand. At the end of 2023, there were more than 70,000 vacancies in the wider acute hospital sector. Staffing shortages in these key areas reduce the ability of hospitals to admit patients quickly from A&E departments or to provide specialist advice to patients within A&E departments who could be treated and discharged, further increasing waiting times.

A picture of activity at A&E departments

Age of patients

NHS Digital publishes detailed annual reports of activity at A&E departments in England. These reports show that the age profile of people attending A&E has remained relatively stable over the past decade, with people aged over 75 and children under 5 years having higher than average number of A&E attendances per person.

Deprivation

People living in the most deprived areas in England had a far higher number and rate of attendances at A&E compared with other groups. A&E attendances were nearly twice as high for people in the most deprived areas as in the least deprived areas.

The first large-scale research into attitudes and perceptions towards emergency care from the 2018 British Social Attitudes survey found that people living in deprived areas are more likely to prefer A&E departments over their GP to get tests done quickly, find it more difficult to get an appointment with their GP, and think A&E doctors are more knowledgeable than GPs. Separate research from the British Red Cross has shown that people who frequently attend A&E account for a substantial share of ambulance and hospital activity, and often face common factors, including housing insecurity, homelessness and mental health issues.

Conditions

One of the defining characteristics of emergency medicine (and general practice) is its undifferentiated case mix – ie, patients attend an A&E department without prior testing or categorisation of their medical condition and health needs. Some of the more common reasons for attending A&E include abdominal pain, chest pain and limb injuries. Over the coming decades, more people are expected to have complex needs and multi-morbidities, which could mean the acuity of A&E patients increases. Early findings from an NHS England trial showed that fewer than expected patients attending A&E were ‘low acuity’.

Winter pressures

Winter is one of the most challenging times for health and care services in general and A&E departments in particular.

Although the volume of A&E attendances is not substantially higher in winter, the demand for hospital admissions and more intensive medical care increases. Demand can rise due to increased prevalence of influenza-like illness, respiratory diseases associated with colder weather such as asthma and pneumonia, and infectious winter vomiting bugs such as norovirus.

These pressures also affect NHS staff, further adding to pressures on services as staff sickness increases over winter. The supply of hospital beds can also be heavily affected by norovirus outbreaks, which can lead to entire wards having to be shut and deep cleaned. This combination of increased demand and reduced capacity leads to people waiting longer in A&E departments over the challenging winter months.

As staffing pressures and reductions in the number of hospital beds have become endemic to the NHS over recent years, long waiting times in A&E departments throughout the year are common.

What is being done nationally to reduce long waiting times in A&E?

In January 2023, following the Covid-19 pandemic, NHS England set out a plan to recover urgent and emergency services. The plan focuses on expanding capacity, growing the workforce, speeding up discharges from hospital, and avoiding admissions by expanding services in the community. It includes three tiers of support from NHS England to local systems, starting with a ‘core offer’ (eg, sharing best practice), then ‘light touch’ (eg, deep dives into challenges), and then ‘intensive support’ for the most challenged systems (eg, buddying with leading urgent and emergency care systems).

As part of this plan, the NHS is developing new models of care that provide care to patients outside an inpatient hospital bed, where appropriate. For example, some A&E patients are being referred to same day emergency care (SDEC) centres that aim to assess, diagnose and start treatment all on the same day. Other patients are being admitted into ‘virtual wards’ rather than physical wards. These new models of care have the potential to reduce demand on A&E departments and therefore improve waiting times.

The previous Conservative government had also announced additional funding to go towards improving urgent and emergency care, including £1 billion in 2023/23 and 2024/25 to expand capacity, and an incentive scheme that offers hospital trusts additional capital funding if they are able to improve their waiting times.

Conclusion

Pressures are rising on A&E departments and people are waiting longer for the care they need as national performance targets are routinely missed.

High levels of hospital bed occupancy, delays in transferring patients out of hospital, and staff shortages throughout the urgent and emergency care system have all had an impact on A&E waiting times over recent years.

The four-hour A&E waiting time standard is one of the most high-profile indicators of how the NHS is performing. The sustained decline in performance against this waiting time standard places a significant toll on patients and staff alike, and is a clear indication of the pressures that the wider health and care system is under.